Jun 6, 2018Lost in Thought
Athletes with attention-deficit/hyperactivity disorder can have difficulty concentrating on the task at hand, which can affect their efforts both on the field and in rehab. Here’s how athletic trainers can help them stay on track.
Attention-deficit/hyperactivity disorder (ADHD)-every athletic trainer has heard of it. But many do not know how to work effectively with athletes who have it.
Let’s change that, starting with a comprehensive definition of the condition. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) defines ADHD as a “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” A patient’s inattention and hyperactivity-impulsivity can be mild, moderate, or severe, and the symptoms can negatively affect their quality of life, relationships, and interactions with others. It is also important to note that those with ADHD face an increased risk for other disorders, such as depression and anxiety.
Because of the everyday struggles ADHD can cause, it is imperative that athletes with this condition are identified and receive the appropriate care, services, and accommodations required for them to be successful in sports and life. Athletic trainers can play a crucial role in this process by being involved in three key areas: assisting with diagnosis, continued maintenance and monitoring, and establishing a plan for handling any mental health emergencies that arise. This article discusses how the athletic trainer can tackle each task to establish a positive, supportive environment for athletes with ADHD.
DIAGNOSIS PROCESS
The first step in effectively managing athletes with ADHD is identification. In the mental health history portion of the annual pre-participation exam (PPE), all athletes should be asked questions about ADHD, such as:
• Have you ever been diagnosed with or screened for an attention or hyperactivity disorder?
• Do you feel that you have significant trouble staying focused during school or completing your daily activities?
If an athlete answers “yes” to a prior diagnosis of ADHD, the athletic trainer and team physician should talk with them about how their disorder is currently being treated, whether they take any medication, past issues they have experienced with managing their ADHD, and what accommodations they have used.
When the athlete’s symptoms are well-controlled, they may not need additional intervention from the medical support staff. However, their initial diagnosis, medications, accommodations, and treatment plan should still be documented to ensure compliance with best practices.
If an athlete has not been diagnosed with ADHD in the past but reports difficulty focusing, they might need to be evaluated for the disorder. Ask if the athlete is open to being tested, and if so, the NCAA’s “Mental Health Best Practices” document (developed in 2016 by the NCAA Sports Science Institute) provides screening guidelines that athletic trainers and team physicians can use.
In the event of a positive screening, a referral can be made to a psychiatrist, psychologist, or family physician to determine whether an ADHD diagnosis is appropriate. The psychiatrist or physician will also be able to prescribe specific medications, if needed, and any of these professionals can offer counseling for the athlete’s symptoms.
An official ADHD diagnosis requires that the patient meet the criteria set forth in the DSM-5, which includes exhibiting at least six inattentive or hyperactivity-impulsivity (or both) behaviors for a minimum of six months. During this six-month time period, athletic trainers may be asked to document the time, date, and outcome for each instance in which the athlete’s symptoms manifest.
The entire ADHD diagnosis process can be very time-consuming and taxing for the athlete. The best way for athletic trainers to approach it is with patience. Remind the athlete that the reason it takes so long is because the health care providers need to ensure the patient receives the best care and treatment. Support the athlete by listening to any frustrations they express along the way.
MAINTENANCE & MONITORING
Regardless of whether an athlete received an ADHD diagnosis in years prior or only after being prompted by the PPE, they will need a treatment plan. It is important for the athletic trainer and team physician to understand an ADHD patient’s plan and provide an environment that supports it.
The first step is being aware of the available treatment options. Depending on the severity of an athlete’s symptoms and how much the disorder affects their quality of life, they may receive pharmacologic and/or non-pharmacologic interventions. Keep in mind that neither are “cures” for ADHD. Rather, they are merely pathways to help diminish the impact of ADHD symptoms.
Pharmacologic treatment-usually in the form of stimulant drugs like Ritalin or Adderall-can be problematic, especially for NCAA athletes. Because these drugs are amphetamine-based stimulants, they are banned by the NCAA as performance-enhancing drugs. Therefore, athletes have to get special permission to take them while participating in NCAA sports. Those who have gone the pharmacologic route report mixed results. Some have had good outcomes with these drugs, claiming they improve their focus in both schoolwork and athletic performance, while others say they make them jittery and irritable and cause sleep problems. Common non-pharmacologic strategies include weekly counseling or tutoring for academic and life guidance.
Once athletic trainers understand treatment options, they can continue to support an athlete’s ADHD management plan by holding routine check-ins with them. These should occur during every annual PPE and as needed throughout the year. Ask how the athlete is doing with their everyday activities, if they have had any issues staying on task or remembering necessary details, and how they’re doing with their treatment program.
The check-ins are also a good time for athletic trainers to ask the athlete and team physician how they can assist with the ADHD management plan. What daily, weekly, or monthly responsibilities should they have? If athletic trainers have questions or concerns about their role, it’s the perfect time to address them.
In addition to the regular check-ins, have a plan in place for when an athlete with ADHD needs coaching for compliance. For example, what will be done if they don’t show up for their weekly rehab/treatment session because they lost track of time? An appropriate response from the athletic trainer would be to ask what they can do to help the athlete remember their appointment for next time. An inappropriate response would be disciplining the athlete in hopes it will keep them from forgetting their future sessions.
Keep in mind that forgetfulness and an inability to focus are hallmarks of ADHD, and it may be difficult for some athletes with ADHD to remember or follow through with their appointments and obligations. Some may think these instances are signs of behavior problems, but they are actually indicative of a disorder that is innate and often uncontrollable.
To that end, athletes with ADHD should never be punished, penalized, or reprimanded for displaying symptoms of their disorder. Just as it is inappropriate, unethical, and, in some cases, illegal to reprimand a person with a physical or intellectual/mental disability, the same applies to patients with ADHD. Thus, athletic trainers need to be mindful of how they address non-compliant athletes with ADHD so that their words and actions are conducive to supporting them, rather than making the situation worse.
Another task athletes who have ADHD might struggle with is focusing in the busy, loud, controlled chaos of the athletic training room. This setting can exacerbate ADHD symptoms, which may make it more difficult for the athlete to concentrate and complete rehab work. Some ways to keep them on task include creating one-on-one treatment times or providing positive verbal encouragement for desired behaviors. (See “Meet the Needs” below for more tips for success.)
PREPARED FOR EMERGENCY
Having a maintenance and monitoring plan is crucial for managing an athlete’s ADHD. However, it’s also recommended to develop an efficacious and comprehensive Mental Health Emergency Action and Management Plan (MHEAMP) to assist in case they experience a mental health crisis. Although these instances are uncommon in individuals with isolated ADHD, because the disorder can often be accompanied by other issues like depression or anxiety, they can arise. It’s important for athletic trainers to be prepared.
When developing , writing, and executing a MHEAMP for a crisis involving an athlete with ADHD, the NCAA “Mental Health Best Practices” document suggests including the following items:
1. Defining what constitutes a mental health emergency for athletes with ADHD. The athletic trainer can talk with the team physician and student health care providers about which situations, symptoms, or harmful behaviors need emergency care and which do not. One common evaluation measure that can be used is asking: “Is the patient a harm to themselves or others?” If so, it’s an emergency and needs to be addressed immediately.
2. Having written procedures in place to mitigate emergencies and immediate threats to safety for athletes with ADHD. Included in this plan should be important phone numbers and any other pertinent information regarding scene safety or school protocols.
3. Identifying what individuals will be deployed when an athlete with ADHD is experiencing a mental health emergency and what their roles will be.
4. Establishing a formal policy on referring athletes with ADHD for emergency mental health care and notifying individuals who will be involved. For example, if an athlete is a harm to themselves or others, the appropriate referral would be to call 911 or the campus authorities. If the athlete isn’t an immediate harm but does need emergency care, the athletic trainer should identify the proper steps to take (i.e., making an urgent appointment with a counselor) so that the individual can be seen in a timely manner.
If an athlete’s ADHD symptoms are well-controlled and frequently checked by their support network and health care providers, the likelihood of needing to activate their MHEAMP is remote. But having the MHEAMP will ensure that all mental health emergencies, no matter how big or small, will be addressed in an appropriate and time-sensitive manner.
There is a lot to consider when it comes to effectively managing athletes with ADHD. But when all of the pieces are combined seamlessly, it sets them up for long-term success.
DIGGING DEEPER
By Laura Ulrich
It’s a busy afternoon, and you’re irritated-your next student-athlete should have been in 15 minutes ago for treatment, but he’s nowhere to be found. Come to think of it, he has missed or been late to several other appointments with you. He forgets how to do the exercises you prescribe-which doesn’t surprise you, since he never seems to be paying attention when you’re describing them. Five more minutes tick by, but still no athlete. You sigh, thinking that if he does show up, at least you’ll be able to give him the sweatshirt he left the last time he was in the athletic training room.
If this sounds like someone you’ve treated, it’s possible that you have worked with a student-athlete who has attention deficit/hyperactivity disorder (ADHD). Before delving into what that means, it’s important to understand what ADHD is not. People often doubt the validity of the condition, assuming it’s caused by factors like poor parenting, too much television or video games, or food additives. Individuals with ADHD are sometimes thought to be lazy, unmotivated, or simply inconsiderate. Frequently, the entire disorder is subject to skepticism: Is ADHD just an excuse for poor behavior?
Using new imaging technology, recent research has answered that question with a definitive “no” by illustrating that ADHD is caused by measurable differences in the brain. People with ADHD have abnormalities related to the neurotransmitters dopamine and norepinephrine. They also have anomalies in brain structure, particularly in the premotor cortex and the prefrontal cortex-two areas that control motor activity and the ability to pay attention. Lastly, they have differences in how various areas of their brains connect and communicate with each other.
These aberrations manifest as the key features of ADHD, which are inattention, hyperactivity, and impulsivity. However, an individual with ADHD may not exhibit symptoms from all three areas. The current edition of the Diagnostic and Statistical Manual of Mental Disorders describes 18 ADHD symptoms, divided into two clusters (inattention and hyperactivity-impulsivity). Inattention symptoms include difficulty staying on task, not seeming to listen when spoken to, not following through on instructions, and being easily distracted. Being unable to stay seated and frequently interrupting when in conversation are some examples of hyperactivity-impulsivity symptoms.
Based on their behaviors, an individual can be diagnosed with ADHD that is predominantly inattentive, predominantly hyperactive-impulsive, or both. To qualify for diagnosis, symptoms have to have started before age 12, be present in more than one setting, and interfere significantly with functioning.
Symptoms of ADHD often become less obvious by adolescence and young adulthood, but they generally don’t disappear and can still cause significant problems. Teens and young adults with ADHD often struggle with restlessness, inattention, poor planning, and impulsivity. With athletes in the athletic training room, this can manifest as failing to attend treatments, forgetting to do rehab exercises, wandering off mentally while you are giving instructions, and leaving behind the list of exercises you provided.
When working with student-athletes who have ADHD, the most important ingredients are compassion, patience, and flexibility. Keep in mind that they are just as smart and motivated as any other player in your care, but that they face significant hurdles in the forms of brain chemistry, structure, and function.
Laura Ulrich is a contributing writer for Training & Conditioning.
MEET THE NEEDS
By David Csillan
Getting an athlete with ADHD to focus in a busy athletic training room can be a challenge, but there are many practical steps athletic trainers can take to help. The keys to success are effective communication and making the athletic training room and rehab protocols ADHD-friendly. Keep the following factors in mind when developing your own plan for rehabbing athletes with ADHD:
They may need a thorough introduction to your protocols. When scheduling the initial evaluation or rehabilitation session, provide uninterrupted one-on-one time to meet with an athlete who has ADHD. Outline and explain their rehabilitation program and answer any questions they have. Conclude the session by taking them through a dry run of their exercises. This first meeting will decrease their anxiety and set the tone for future interactions.
Clear communication is necessary. In order to eliminate confusion and misunderstandings, literal discussions are best. ADHD and sarcasm are a toxic mixture, as athletes with ADHD may not be able to pick up on exaggerations. Therefore, keep all instructions brief and to the point.
An athlete with ADHD may be touch-sensitive. This can cause them to withdraw quickly from a typical hands-on evaluation or ice bag application. An explanation should precede any physical contact. When applying an ice bag to the skin, gradually introduce the cold. First utilize a towel barrier, and then remove it after a few minutes.
Athletes with ADHD may be easily distracted and have difficulty staying on task. External stimuli, such as other athletes conversing in the athletic training room, a song playing on the radio, or the whirring of the ice machine, may interrupt their focus with rehabilitation. For this reason, it is important to provide subtle cues to rein them back in. The cues, which can be established during the initial evaluation session, may range from a small tap on the treatment table to a wink or code word.
Rehab should be simple and easy to follow. Outline the rehabilitation program using a clear, concise checklist that allows athletes to cross off exercises as they are completed. In addition, since the athlete will need to rely on their checklist for reference, it should be readily accessible.
The athletic training room should be easy to navigate. Using labels, numbers, and colors creates a stress-free environment for the athlete with ADHD. Exercise equipment can be marked for quick identification. For instance, you can use dumbbells that have a colored vinyl coating so it’s easy to tell the different weights apart. If there are multiple treatment tables in the room, attach numbers to the base of each. These small steps allow the athlete to be self-sufficient in their rehab and minimize interruptions for the athletic trainer when they are working with other patients.
Athletes with ADHD often thrive on attention and achieving goals. Include both in their rehab protocol. However, any goals must be short-term and attainable. Too long of a gap between accomplishments may cause the athlete to experience anxiety or depression with their lack of progress. In addition, providing immediate rewards for achieving short-term goals will keep them motivated and compliant with their program.
Each individual is different. Just as the severity of injuries can vary from athlete to athlete, so do the specific needs of athletes with ADHD. By the time they reach high school or college, most have a grasp on their disorder and can provide tips on how to best help them succeed. Also, the athletic trainer may consult with the school psychologist or review the athlete’s Individualized Education Program or 504 Plan with their guidance counselor to better understand what accommodations to make.
David Csillan, MS, LAT, ATC, is Athletic Trainer at Ewing (N.J.) High School and a member of the New Jersey State Interscholastic Athletic Association’s (NJSIAA) Sports Medicine Advisory Committee. He also serves as the NATA District 2 Secretary, Secretary Vice-Chair of the NATA District Secretaries/Treasurers Committee, and the NJSIAA Liaison with the NATA and NFHS. He can be reached at: [email protected].
To view the references for this article, go to: Training-Conditioning.com/References.
This article appeared in the May/June 2018 issue of Training & Conditioning.
